11-03-11P12:02 RCVD

Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

. . OMB Number: 0920-0639 Expires: 09/20/2013
Petitioner Authorization Form Page 1 of 2

Use of this form and disclosure of Social Security Number are voluntary. Fallure to use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitled,

Instructions:

lf you wish to petition HHS to consider adding a class of employees to the Special Exposure Cohort and you
are NOT either a member of that class, a survivor of a member of that class, or a labor organization
representing or having represented members of that class, then 42 CFR Part 83, Section 83.7(c) requires
that you obtain written authorization. You can obtain such authorization from either an employee who is a
member of the class or a survivor of such an employee. You may use this form to obtain such authorization
and submit the completed form to NIOSH with the related petition. Please print legibly.

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-8570.

Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Employees for

Addition to the Special Exposure Cohort

Name of Class Member or Survivor

Street Address of Class Member or Survivor Apt. # P.O. Box

City, State, Zip Code of Class Member or Survivor

do hereby authorize:

Name of Petitioner

Address of Petitioner Apt. # P.O. Box

City, State and Zip Code of Petitioner

to petition the Department of Health and Human Services on behalf of a class of employees
that includes:

Name of Class Member (employee, not the employee's survivor)

for the addition of the class to the Special Exposure Cohort, under the Energy Employee’s
Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385).

In pro g this authorization, | recognize that the petitioner named above will have all the rights

of apetitioner as provided for under 42 CFR Part 83.
lo Sa & / 2 o//
7

Signature of Class Member or Survivor Date

Name or Social Security Number of First Petitioner:



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Contro! and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 09/20/2013
Petitioner Authorization Form Page 2 of 2

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 3 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.
Persons are not required to respond to the information collected on this form unless it displays a currently
valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the
following:

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional
classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEQICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed
below.

NIOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal
agencies, other government or private entities arid to private sector employers to permit these entities to
retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these
individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a
Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition.

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit, or
privilege to which you may be entitled.

Name or Social Security Number of First Petitioner:


O'‘FICIAL BUSINESS
Penalty for Private Use $300

BUSINESS REPLY MAIL

FIRST CLASS MAIL PERMIT NO. 99110 ATLANTA, GA 30333

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